Adult research suggests that the dissociation criterion of acute stress disorder has limited validity in predicting posttraumatic stress disorder (PTSD). We addressed this issue in child and adolescent survivors (n=367) of road accidents. Dissociation accounted for no significant unique variance in later PTSD, over and above other acute stress disorder criteria. Furthermore, thresholds of either three or more re-experiencing symptoms, or six or more re-experiencing/hyperarousal symptoms, were as effective at predicting PTSD as the full acute stress disorder diagnosis.

Hypothalamic–pituitary–adrenal (HPA) axis sensitivity was investigated in 32 non-medicated patients with borderline personality disorder without comorbid post-traumatic syndromes and in 18 normal individuals using a modified dexamethasone suppression test (0.25 mg). Enhanced cortisol suppression was found in the patients v. controls (P < 0.05) and the percentage of participant's with non-suppression was smaller in the patient (34%) than in the control group (89%) (P < 0.01). Baseline cortisol levels in the patients were also lower than in the controls (P < 0.05). The 0.25 mg dexamethasone suppression test reveals increased feedback inhibition of the HPA in borderline personality disorder.

Background This study explores the temporal relationship between anxiety and major depressive disorders in a cohort of patients with current major depression.

Method Current prevalence and lifetime history of specific anxiety disorders were assessed using the Structured Clinical Interview for DSM–III–R Diagnosis (SCID–P) in 85 patients with DSM–III–R major depression. Consensus DSM–III–R diagnoses were assigned by at least two psychiatrists or psychologists.

Results Twenty-nine per cent met criteria for at least one current anxiety disorder and 34% had at least one anxiety disorder at some point in their lives. The mean (s.d.) age of onset of anxiety disorder in the depressed patients with comorbid social or simple phobia (15 (9) years) was significantly younger than was that of their major depression (25 (9) years). In contrast, the mean (s.d.) age of onset of anxiety in patients with comorbid panic or OCD (20 (8) years) was similar to that seen for their major depression (21 (9) years). In patients with major depression with comorbid anxiety disorders, both the social phobia (10 of 13) and simple phobia (4 of 4) were more commonly reported to start at least two years prior to their major depression in contrast to depressives with comorbid panic (3 of 10 subjects) – Fisher's exact test, P=0.01.

Conclusions Early-onset social and simple phobias appear to be risk factors for later onset of major depression.

The comparative value of possible therapeutic factors in group psychotherapy was studied by submitting questionnaires regularly to patients and therapists of six long-term out-patient groups. Both patients and therapists attached most importance to self-understanding, self-disclosure and learning from interpersonal actions. They diverged, however, in their overall perception of which factors were important in therapy.

The traditional psychiatric belief that homosexual women are emotionally unstable (3, 10, 21) has been challenged by Armon (1), Freedman (11), and Hopkins (13). The contention that such women are neurotic has typically been voiced by clinicians reporting on their own therapy patients (3, 10, 19). One exception is the recent psychometric investigation by Kenyon (15) who studied a non-clinical group of English homosexual women, and concluded that they were higher in neuroticism than a comparison group of heterosexuals. In contrast to the ‘illness' notion of homosexuality, the authors of three psychometric studies (1, 11, 13) dealing with non-clinical homosexuals and heterosexuals reported that heterosexual women were not better adjusted than homosexuals. The paucity of research in this area is exemplified by the fact that a total of only four studies, noted above, have been found to date by this author. Even the clinical literature, which is replete with case studies and therapeutic discussions concerning male homosexuality, is strikingly sparse in the area of lesbianism (19). The present study was therefore conducted to add to the small body of data we now have on the adjustment of homosexual versus heterosexual women.

Anxiety and affective symptoms are prominent features of schizophrenia which are often present in the prodromal phase of the illness and preceding psychotic relapses. A number of studies suggest that genetic risk for the disorder may be associated with increased anxiety long before the onset of psychotic symptoms. Targeting anxiety symptoms may represent an important strategy for primary and secondary prevention in schizophrenia.

The term ‘dysmorphophobia’ was first defined by Morselli (1886) who wrote of it as “a subjective feeling of ugliness or physical defect which the patient feels is noticeable to others, although his appearance is within normal limits”. A century later there is continuing debate as to its status as symptom, syndrome or discrete psychiatric illness. Misleadingly, it is not a phobia and there is no fear of physical abnormality per se – the ugliness of others is tolerated, although the patient may well be apprehensive regarding the response he anticipates his appearance will provoke in others. As a symptom the feeling may be expressed as a preoccupation with appearance, an obsession, overvalued idea or frank delusion. The accompanying self-consciousness may similarly range to full-blown delusions of reference. To some extent the failure of some authors, reporting on dysmorphophobic patients, to specify clearly the level at which the belief is held, has confounded clarification of the phenomenon.

This paper represents an attempt to measure the reliability of the clinical assessment of the reaction to pain and further to estimate the significance of this reaction in a group of chronic schizophrenic patients.

The definition and clinical aspects of rapid cycling affective illness are reviewed and various factors associated with the onset and maintenance of rapid cycling enumerated. On the basis of this information and of reports of the response of rapid cycling patients to various treatment interventions, an approach is suggested to the evaluation and treatment of rapid cycling affective illness.

The validity of the concept of situational (i.e. reactive) depression as distinct from other major depressive subtypes is examined in terms of psychosocial stressors, personality features, current symptomatology, and clinical course and follow-up. Thirty-eight patients with a recent onset of situational major depressive disorder (i.e. the disorder developed after an event or in a situation the diagnostician deemed likely to have contributed to the episode at that time) were compared with 68 non-situational major depressive patients. These patients were participants in the clinical studies of the NIMH-Clinical Research Branch Collaborative Program on the Psychobiology of Depression. No significant differences between the two groups were found in the total number, content areas, or other categorizations of life events, experienced prior to onset. Some statistically significant differences in current symptomatology and in clinical course and follow-up measures were obtained, but there were none in personality traits. Implications of these results in relation to previously published reports are discussed and caution is recommended in the use of the term situational depression until more definitive data become available.

The corpus callosum, a cerebral commissure of 200,000,000 fibres, is thickened in chronic schizophrenia and several neuropsychological and neurophysiological techniques have suggested poor links between the two cerebral hemispheres. The interhemispheric conduction time across the corpus callosum, measured in 12 schizophrenics, using the ipsilateral/contralateral latency differences of the early somatosensory evoked response, was found to be effectively zero. It is suggested that schizophrenia is a split-brain condition akin to agenesis of the corpus callosum, unrecognized through the use of compensatory ipsilateral sensory pathways.

One hundred and six women were assessed psychiatrically in the 14–16th and 36–38th weeks of pregnancy and the 12th week after childbirth. They also completed a maternity blues questionnaire daily in the ten days after delivery. Blues scores were significantly associated with: neuroticism; anxiety and depressed mood during pregnancy; fear of labour; poor social adjustment; and retrospective severity of pre-menstrual tension. Blues scores were not associated with obstetric factors, with previous history of psychiatric disorder, or with case status on the PSE in pregnancy or 12 weeks after delivery.

The ‘conversational model’ of psychotherapy was investigated with a view to discovering which behaviours distinguish psychotherapists trained in this method from others, of equal clinical experience. A rating scheme designed to capture the theoretical aspects of the model, and 30 predictions were made concerning behaviours which were expected to distinguish the psychotherapists. Five psychotherapists were matched to five psychiatrists who had not been trained in this method; each doctor took on four patients for therapy, and each patient was seen on five occasions. All interviews were recorded, and excerpts from the recordings rated. Only ten of the 30 predictions were upheld. In ten further predictions, the psychotherapists displayed the appropriate behaviours, but the behaviours were not peculiar to the model, since eclectic psychiatrists also displayed them. Six model behaviours were not practised frequently by the psychotherapists, and four ‘non-model’ behaviours were equally common in either group. The research formed the basis for the preparation of materials to teach psychotherapeutic skills in a more efficient way.

A great deal is known about men who display a stable pattern of antisocial behaviour since childhood. However, more research is needed to identify subtypes within this population so as to further understanding of the causal processes that initiate and maintain violent behaviours and to identify interventions that specifically target the deficits presented by each subtype. Evidence-based practice means not only using treatments proven to be effective but also basing conceptualisations of disorders on scientific evidence.

The scope of this introductory contribution is to present some general facts and ideas which could enhance our understanding of this enigmatic illness. By ‘mediating processes’ (or ‘mediators’) I mean mechanisms providing bridges between different aspects of knowledge of the schizophrenia-puzzle which, so far, have not been linked together in a satisfactory way: one of the central problems is the identification of mediators between psychosocial factors on the one hand, and biological factors on the other. If we do not succeed in building up conceptually valid bridges between these two aspects, which are testable for hypothesis-orientated research, a disastrous splitting of our understanding and treatment of schizophrenia into either biological or psychosocial reductionism is likely.